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Contribute more to the health system by smoking? Five key concepts to better understand what is behind this debate


Laura van der Werf Paintings
MBE Researcher

In recent days we published a survey in which we asked if it would be fair for those who smoke to contribute more to the financing of the health system than those who do not. More generally, this question is about whether all members of society should finance the risks taken by those people who have habits that we now know increase the risk of disease. But what arguments are there for and against contributions to the health system being proportional to the risk taken?

Why do we insure?fu1

Health insurance is a contract in which the insurer agrees to pay for the services required by the insured in case of illness, in exchange for a regular payment called a premium. The purpose of having health insurance is to financial protection, which consists of preventing direct payments to obtain health services from being so high in the event of illness that they can lead to serious financial difficulties that threaten their living standards (1).


Financial protection is important because it ensures that people have access to health services if they need them, regardless of whether or not they have the resources to pay for them directly, thus protecting the right to health.


Health insurance and risk behaviors

Insurance is possible because people's care costs are distributed asymmetrically. This means that most of the resources are spent to cover the costs generated by relatively few people, while the rest of them consume a much lower amount of resources. The problem, however, is that the expected expenditure is also distributed asymmetrically: it can be predicted that some people will consume more resources than others. For example, people who smoke are more likely to get sick more often or more seriously, or people who have chronic illnesses are more likely to consume more resources.


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These differences in the probability of consuming resources lead to incentives to avoid insuring or charging a higher premium to those people who are at higher risk of becoming ill. These practices are known as risk selection and rating (2,3).



On the other hand, the fact that people are insured can promote behaviors that increase the risk of getting sick or using health services in an excessive way, by not having to fully cover the costs of using them. This is called moral hazard (4).fu3


Why charge more to those who take more risks?

In our survey, the majority of people (75.6%) considered that it would be fair for people who smoke to contribute more to financing the health system. An argument used in favor is that these people must contribute more to the health system because of their bad habits, which in turn can discourage those bad habits.



The other argument that is used is that it is not fair that people who take fewer risks associated with negative consequences have to pay for people who take more of these types of risks. Behind this way of understanding justice is a principle called actuarial equity. According to this concept, people should pay proportionally to the risk to which they are exposed, since it is not considered fair that those who take less negative risks have to pay for those who take those risks more (5).



Why charge the same to those who take more risks?

Among those who consider that it is not fair that those who smoke have to contribute more to the financing of the health system, they argue that smoking is an addiction, that is, it is a disease over which people have no absolute control. In fact, only between 3 and 5% of patients manage to stop smoking autonomously, between 7 and 16% they achieve it with a behavioral intervention and around 24% they achieve it when they receive both drug treatment and behavioral interventions (6). It is difficult to define where the line should be drawn between risk factors over which people have control and over which people have no control. Would it be fair to charge a person more for being exposed to a risk factor over which they do not have control?


Another argument against contributions to the health system being proportional to risk is that this would make it difficult for the people who most need access to health services to access them. This has been described as the reverse care law, according to which the availability of good health coverage tends to vary inversely with the need for it (2). When access to insurance is more difficult for those most at risk of becoming ill, these individuals (and their families) are no longer financially protected.


The principle underlying payment not proportional to the risk of getting sick is the fu5solidarity, more specifically risk solidarity. According to this principle, those people who are at low risk of getting sick should subsidize people who are at high risk of getting sick.


And in Colombia, how does this work?

Behind the way in which the health systems of each country are configured, there are principles that are considered more or less important in each one of them. While in countries like the United States, actuarial equity is considered a more important principle than risk solidarity, in many European countries risk solidarity prevails over actuarial equity.


In Colombia, within the principles of the General System of Social Security in Health is solidarity, defined as the practice of mutual support to guarantee access and sustainability to Social Security in Health services. There is also the principle of co-responsibility, according to which everyone must strive for their self-care, for the health care of their family and their community, a healthy environment, the rational and adequate use of the resources of the General System Social Security in Health and fulfill the duties of solidarity, participation and collaboration.


At least on paper, the predominant principle is solidarity, however, it is also sought that people take care of their own health and use health services appropriately. The health system needs to find ways to encourage self-care, without jeopardizing financial protection, access to health services and consequently the guarantee of the right to health. Soon on our blog we will be telling you more about issues related to promoting healthy habits through health policies.


1. QUIEN. WHO | Financial protection [Internet]. QUIEN. World Health Organization; 2018 [cited 2019 Mar 25]. Available from: https://www.who.int/health_financing/topics/financial-protection/en/

2. Light DW. The practice and ethics of risk-rated health insurance. JAMA. 1992 May; 267 (18): 2503–8.

3. Ellis RP, Fernandez JG. Risk selection, risk adjustment and choice: concepts and lessons from the Americas. Int J Environ Res Public Health [Internet]. 2013 Oct 25; 10 (11): 5299–332. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24284351

4. Donaldson C, Gerard K. Countering moral hazard in public and private health care systems: a review of recent evidence. J Soc Policy. 1989 Apr; 18 (2): 235–51.

5. Landes X. How Fair Is Actuarial Fairness? J Bus Ethics [Internet]. 2015; 128 (3): 519–33. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=102426091&site=eds-live

6. Laniado-Laborin R. Smoking cessation intervention: an evidence-based approach. Postgrad Med. 2010 Mar; 122 (2): 74–82

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2 years ago

I fully agree that a system must be changed that allows the difference between those who take care of themselves and those who do not, it is not the definitive or only solution that solves the problems, but the negative incentives for smoking, not exercising, inadequate diets have to be contributing more to the system.

2 years ago

Various topics: 1) Insurance is a strategy, a means, to guarantee access to health services (see Law 1751 of 2015). 2) In the same way that SOAT is only charged to people who have a vehicle or toll to those who travel on a road (although we all contribute in a lesser proportion to these as the cost of the products or services we consume, it would not be strange to charge an additional tax on those who generate other risks - for themselves or for other citizens - such as when deciding to smoke. 3) That it is easy or difficult to stop smoking does not count for the analysis, nor is it the case to relate it only to putting a tax on the Pollution, as it is a different risk, and the talk is of taxing the risk-generating chain: those who produce, sell and consume, in the same way that the tax on sugary drinks has been talked about. 4) Setting a tax is not intended to be a single effective measure or exclusive of others, nor are road prevention programs or technical-mechanical review or the use of helmets on motorcycles being ignored.

Victoria Eusse
2 years ago

I agree with the epidemiological vision of tobacco use. It is a community health problem caused by people who have an addiction.
And I would not be very sure that the increase in the contribution to the health system by "nicotine addicts" discourages its use, precisely because it is an addiction and these are not controlled in a rational way; the problem is mental health, which I really don't think can be reduced in a punitive way. We see this on a daily basis with many addictions.
Being able to reduce them has more to do with educational and preventive mental health programs as true public policies.

Alonso Verdugo
2 years ago

And the massive smoker? or the risks of contamination, for example vehicle axles?
These actuarial risks under the sophism of equality seek where to fund the risks of living.
the most equitable is the population risk ... or where are the motorcyclists and the soat?

Manuel Cardozo placeholder image
2 years ago

Smoking, like any other addiction, is a disease, just like diabetes. I believe that the approach is wrong and protects the financial interests of the insurers, rather than worrying about the health of the patient. In the same way, should those who consume salt be charged more? Who consume fat? Who consume sugar? Or those who work exposed to toxic products? The additional payment is made in the taxes charged to the products, but the health system can in no way discriminate against any member for suffering from a disease.

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